Patient Intake Information Intake Form Have you ever been in treatment before? If yes, where and how long?: * Have you ever used IV (Needles) before? * When was your most recent Suboxone/Subutex prescription (date)? * Have you been tested for Hep C? Did you test positive or negative? * Have you ever been in rehab or detox before? If yes, when and where? * Were you referred by anyone? If yes, please enter their name. * What was your drug of choice? (drug that led to addiction) * How long have you been struggling with Opioid Addiction? * Do you smoke cigarettes? If yes, how many daily? * Do you have any allergies? If yes, please provide documentation. * Are you prescribed any other medications? Please list them. * FOR FEMALES: Are you pregnant or breastfeeding? * Name * Name First Name First Name Last Name Last Name Date of Birth Email * Phone Number * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency Contact Name * Emergency Contact Name First Name First Name Last Name Last Name Emergency Contact Relationship * Emergency Contact Phone * Recovery Plan Status Crisis Plan in Place * Yes No Include any specific steps or contacts Support System Access to Harmful Means Yes No Include safety plan Please upload photo id only * Drop a file here or click to upload Choose File Maximum file size: 104.86MB Buprenorphine Consent/Treatment Plan Buprenorphine Consent I understand that becoming a buprenorphine patient means that I am admitting to being dependent on opioids and am seeking maintenance treatment for my addiction. I understand that I cannot see multiple physicians for this type of treatment at the same time, or receive other buprenorphine containing prescriptions I understand that physicians who provide buprenorphine treatment at WBK Healthcare Services facility only treat for opiate addiction and not for Pain management. I understand that by becoming a buprenorphine patient I will be required to attend counseling services for at least 2 hours per month and I will be referred to outside counseling services in the surrounding area. I understand that each treating physician has access to the PDMP, OARRS & CSAPP systems which can track any other medication I am prescribed and fill at a pharmacy. I understand that while in treatment I am not allowed to be prescribed any opiates or benzodiazepine prescriptions without the consent of the treating physician. I understand that if I am suspected or caught or diverting my medication I will be automatically discharged and will be reported to other local facilities and law enforcement. I understand that my urines will be monitored by video surveillance and will be sent out to a laboratory so that my treating physician can get the most accurate results of my screening. I also submit to random medication counts for my entire treatment. I also understand that I will be given a baseline physical exam (vitals) and review a treatment plan with my physician during my initial visit. I acknowledge that if I am discharged for breaking any policies that I will not be refunded for any payments made. Initial Treatment Plan Goals Patient will have 4 weeks to eliminate all illicit drug use. Patient will have 4 weeks to sign up and complete monthly counseling requirement. Patient will take medication as prescribed. Patient will also begin to focus on building a positive support system. Patient will also work with physician on additional goals that will allow them to accelerate their success in treatment, Plan Physician will make sure that patients are following all policies and procedures. Physician will also refer patients to additional services as deemed necessary. Physician will determine how frequently patients should return for follow-up appointments. Physician will monitor PDMP, OARRS, and/or CSAPP before each patient visit Signature * signature keyboard Clear Confidentiality and Release of Information Confidentiality Statement You are hereby notified that the confidentiality of patients is protected by Federal and State laws. You cannot reveal the identity, whereabouts, or status of any patient in this program without his or her WRITTEN CONSENT. Attached you will find a copy of Federal regulations pertaining to confidentiality, and additional information in the Federal Regulations 42 C.F.R. Part 2 (June 9, 1987) and,45 C.F.R. § 164.520. I fully agree to comply with the laws of confidentiality regarding patients and records held by WBK Healthcare Services and that any breach of confidentiality pertaining to the aforementioned will result in legal action being taken against you. Consent to RELEASE Information I authorize my treating physician to release information to: Any Pharmacy that I (Patient) decide to fill my buprenorphine prescription at, also to any other physician that prescribes me any additional medication that can affect my current treatment for opioid dependence. I also give permission to release limited information (Nature of emergency) to my listed emergency contact (Emergencies only).In addition I give my permission to release information to those that I personally give legal consent to this includes outside agencies such as CYS/CPS and court appointed attorneys The specific information to be released is: ( x ) Whether or not the patient is in treatment ( x ) Nature of emergency ( x ) Diagnosis and prognosis ( x ) Medical records ( x) Brief description of patient’s progress ( x ) Pharmaceutical Inquiries ( x ) Nature of services provided ( x ) Patient Pharmacy ( x ) Whether patient has relapsed I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Chapter I, Part 2 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this consent verbally or in writing at any time except to the extent that action has been taken in reliance on it. If not previously requested, this consent will expire 6 Months after patient exits from treatment . Unless I have specifically requested in writing that the disclosure be made in a certain format, my treating physician reserves the right to disclose information permitted by this authorization in any manner deemed to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically. Federal law prohibits a person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR, Chapter I, Part 2. I understand that I may contact the main office for answers to my questions about the privacy of my health information at 114 Werner St. Bridgeville PA 15017, or by telephone at (412) 314-1822. Signature * signature keyboard Clear Submit If you are human, leave this field blank.
